Condom Social Maketing: Selected Case Studies Joint United Nations Pogamme on HIV/AIDS UNICEF UNDP UNFPA UNDCP UNESCO WHO WORLD BANK
Acknowledgements These case studies wee pepaed by Michael P. Fox, Consultant, fo the Depatment of Policy, Stategy and Reseach (PSR), UNAIDS, Geneva, with significant contibutions of time, infomation, data and mateials fom the head offices and national poject offices of Population Sevices Intenational, The Futues Goup Euope, Intenational Family Health, as well as fom the Asociación Colombiana Po-bienesta de la Familia (PROFAMILIA) and Johns Hopkins Univesity /Cente fo Communication Pogams. In addition, valuable inputs wee given by Mitchell Waen and the AIDSMak poject. The case studies poject was initiated and coodinated by Bunmi Makinwa, Communications Advise, PSR, UNAIDS. UNAIDS/00.37E (English oiginal, Novembe 2000) ISBN 92-9173-018-1 Joint United Nations Pogamme on HIV/AIDS (UNAIDS) 2000. This document is not a fomal publication of UNAIDS and WHO and all ights ae eseved by these bodies. The document may, howeve, be feely eviewed, quoted, epoduced o tanslated, in pat o in full, povided the souce is acknowledged. The document may not be sold o used in conjunction with commecial puposes without pio witten appoval fom UNAIDS (contact: UNAIDS Infomation Cente). The views expessed in documents by named authos ae solely the esponsibility of those authos. The designations employed and the pesentation of the mateial in this wok do not imply the expession of any opinion whatsoeve on the pat of UNAIDS concening the legal status of any county, teitoy, city o aea o of its authoities, o concening the delimitation of its fonties and boundaies. The mention of specific companies o of cetain manufactues poducts does not imply that they ae endosed o ecommended by UNAIDS in pefeence to othes of a simila natue that ae not mentioned. Eos and omissions excepted, the names of popietay poducts ae distinguished by initial capital lettes. UNAIDS - 20 avenue Appia - 1211 Geneva 27 - Switzeland Telephone: (+41 22) 791 46 51 - Fax: (+41 22) 791 41 87 E-mail: unaids@unaids.og - Intenet: http://www.unaids.og
U N A I D S B E S T P R A C T I C E C O L L E C T I O N Condom Social Maketing: Selected Case Studies Joint United Nations Pogamme on HIV/AIDS UNICEF UNDP UNFPA UNDCP UNESCO WHO WORLD BANK Geneva, Switzeland Novembe 2000
Condom Social Maketing Table of Contents 1. Intoduction 5 2. What is social maketing? 6 Condom social maketing 7 The ole of UNAIDS in social maketing 7 3. Diffeent appoaches to social maketing 9 4. Case studies 12 Community-based distibution in Haiti and Mozambique 12 - Haiti 13 - Mozambique 19 Community-based social maketing in India 24 Social maketing based on tageted sevice delivey in Cameoon 29 Social maketing with existing commecial bands in Kenya 35 A local pivate secto initiative in social maketing in Colombia 39 5. Key lessons 47 6. Selected bibliogaphy (pincipal souces) 49 3
UNAIDS Aconyms AIDS CA CBD CBO CBSM CSM DHMT DKT FGE FP FPAK GTZ HIV IEC IFH IICH IPPF KAP MCH NACP NGO PMSC PROFAMILIA PSI SM STD TFGI UK /DFID UNAIDS UNDP UNFPA UNICEF USAID WHO Acquied immunodeficiency syndome Community agent Community-based distibuto Community-based oganization Community-based social maketing Condom social maketing Distict health management team DKT Intenational The Futues Goup Euope Family planning Family Planning Association of Kenya Deutsche Gesellschaft fü Technische Zusammenabeit Human immunodeficiency vius Infomation, education and communication Intenational Family Health Indian Institute of Community Health Intenational Planned Paenthood Fedeation Knowledge, attitude and pactice Matenal and child health National AIDS Contol Pogamme Nongovenmental oganization Pogamme de Maketing Social au Cameoun Asociación Colombiana Po-bienesta de la Familia Population Sevices Intenational Social Maketing Sexually tansmitted disease The Futues Goup Intenational United Kingdom /Depatment fo Intenational Development Joint United Nations Pogamme on HIV/AIDS United Nations Development Pogamme United Nations Population Fund United Nations Childen s Fund United States Agency fo Intenational Development Wold Health Oganization 4
Condom Social Maketing 1. Intoduction Since its establishment in 1996, UNAIDS has pomoted and suppoted social maketing, and especially the social maketing of condoms, as a key stategy in the fight against the spead of HIV/AIDS and STDs. Social maketing pojects and pogammes exist in dozens of developing counties but, at the same time, thee ae still many moe counties with the potential to adopt o expand simila activities. This document is the fouth in a seies on social maketing poduced by UNAIDS to povide basic infomation on this activity and how its concepts and techniques may be applied in esponse to the spead of HIV/AIDS, paticulaly in developing counties. Pevious documents wee Social Maketing: An Effective Tool in the Global Response to HIV/AIDS, as an intoduction to social maketing which descibes its main concepts and techniques; Social Maketing: Expanding Access to Essential Poducts and Sevices, which highlights lessons leaned fom thee examples of social maketing applied to male and female condom pomotion in developing counties; and A Global Diectoy of Condom Social Maketing Pojects and Pogammes, as a compendium of existing condom social maketing pojects in 1999. Condom Social Maketing: Selected Case Studies pesents six applications of diffeent social maketing techniques dawn fom among on-going pojects in developing counties in the field of epoductive health and pevention of HIV/AIDS and STDs. Individually they illustate diffeent, eal-life appoaches to condom pomotion though social maketing in esponse to paticula challenges and needs. All descibe activities fom which significant lessons may be leaned. In addition, they demonstate the flexibility of social maketing and how the technique can be adapted to deal with diffeing situations and constaints. The booklet is intended mainly fo distibution to individuals and oganizations, fom both the public and pivate sectos, who ae inteested in leaning moe about social maketing, and how its concepts and techniques can be applied in esponse to the spead of HIV/AIDS and STDs, paticulaly in developing counties. It is also intended to povide basic infomation, as an aid to taining, pogamme planning and elated activities. 5
UNAIDS 2. What is social maketing? Social maketing may be defined as the adaptation of commecial maketing and sales concepts and techniques to the attainment of social goals. It seeks to make health-elated infomation, poducts and sevices easily available and affodable to lowincome populations and those at isk while at the same time pomoting the adoption of healthie behaviou. In fact, it may be said that the ultimate goal of social maketing is to effect healthy and sustainable behaviou change. Making quality poducts and sevices affodable and available is just one pat of the social maketing equation. Encouaging thei use epesents the othe. Maket eseach and a stong communications component ae essential to the success of a social maketing pogamme. Social maketing has become inceasingly popula among govenments and donos as an efficient and effective means of addessing seious health issues in developing counties. It has its oots in family planning but the concept is now applied acoss many fields in public life and health, in both developed and developing counties, including such aeas as potection of the envionment, campaigns against smoking and alcohol abuse, and the pevention and cae of malaia, leposy and tubeculosis. Howeve, the use of social maketing in esponse to the challenge of impoving the sexual and epoductive health of women and men in developing counties has attacted paticula attention. Social maketing complements, and does not eplace (o even seek to eplace), fee access to health sevices and poducts. It theefoe does not compete with the public health system and in fact suppots existing systems. By making low-cost poducts available outside the health system, social maketing pogammes alleviate the pessue on existing sevices and thus allow the health system to use limited esouces moe efficiently. In addition, and paticulaly in the case of condoms, social maketing can be an altenative souce of poducts and infomation fo people who may be unable o unwilling to access locations whee pivacy is too often impaied. Fo instance, though social maketing condoms ae widely available in places whee people outinely go, as opposed to epoductive health clinics, which tend to be much less fequented by men and young people. The possibility of anonymity in a commecial tansaction then becomes attactive, paticulaly to women and sexually active young people. Govenment suppot, then, is key to the success of social maketing pogammes and these ae often developed in close collaboation with host county govenments in line with national pioities and needs. Many govenments ecognize the significant contibutions of social maketing to impoving the sexual and epoductive health of thei low-income populations and extend impotant financial and political suppot to the activity. In many counties, fo example, socially maketed poducts, fequently condoms, ae allowed tax exemptions o may be diectly subsidized by local o national govenment in ode to educe costs and pices; othe examples include the use of IEC mateials developed by social maketing in public schools and clinics, o the elaxation of estictions on 6
Condom Social Maketing the use of mass media fo educational communications on sexual and epoductive health issues. Condoms ae a case in point, whee only a few yeas ago it was vey ae to find a county whee advetising this poduct was pemitted in the mass media channels, something that has now become quite common. Condom social maketing In the mid-1980s, condom social maketing (CSM) emeged as an effective tool in combating the spead of HIV/AIDS. Though social maketing pogammes and pojects in many counties affected by the epidemic condoms have become moe easily available, affodable and acceptable to sexually active men, women and young people in geneal as well as to those in high-isk goups. Although the pogammes have geneally focused on the poduct, concomitant communications and IEC activities have significantly contibuted to aised awaeness of the isks of infection and the means of pevention, eaching people, govenments and institutions in all sectos of public and pivate life. Condom social maketing pogammes have made condoms moe accessible, affodable and acceptable in many of the wold s pooest counties. In 1997 these distibuted about 900 million male and female condoms. By 1999, at least 71 diffeent social maketing pogammes fo male and female condoms wee active in 59 developing counties. It has been said that in the case of condoms social maketing has acted as a nomalize of the poduct, educing the stigmas populaly attached to it. Until ecently in many developing counties, public access to condoms was difficult as the poduct was often available only in phamacies and health clinics and geneally thought to be moe appopiate fo use by and with commecial sex wokes. Now, thanks to yeas of pesistent social maketing activities, condoms in many counties ae widely available fom a vaiety of outlets, openly discussed in public and in the media, and ae seen by many, including many of those at high isk of HIV infection, to be common household items. The destigmatization of condoms in many counties illustates how social maketing can help populations to ovecome social and cultual esistance to pactising effective pevention of STDs and HIV/AIDS. The ole of UNAIDS in social maketing The Joint United Nations Pogamme on HIV/AIDS (UNAIDS) is the leading advocate fo global action on HIV/AIDS. UNAIDS leads, stengthens and suppots an expanded esponse aimed at peventing the tansmission of HIV, poviding cae and suppot, educing the vulneability of individuals and communities, and alleviating the impact of the epidemic. Since its establishment in 1996, UNAIDS has pomoted and suppoted social maketing, and paticulaly the social maketing of condoms, as a key stategy in the fight against the spead of HIV and AIDS. 7
UNAIDS As a cosponsoed pogamme, UNAIDS plays a unique and impotant ole in ganeing suppot fo social maketing pogammes. At the national level, UNAIDS encouages govenments and NGOs to suppot, develop and implement HIV/AIDS pevention social maketing initiatives within thei counties. This may include advocating fo the inclusion of social maketing in national plans, the allocation of esouces to social maketing pogammes fom multilateal and bilateal donos, and the facilitation of a positive legislative envionment fo social maketing. The exchange of expeiences between oganizations and counties is also encouaged. In counties whee social maketing pogammes ae being launched, UNAIDS takes an active ole as fundaise and, moe ecently, as a potential povide of technical assistance in collaboation with leading social maketing oganizations, such as Population Sevices Intenational (PSI) and supplies of poducts, such as with The Female Health Company, sole manufactue of female condoms. In addition, though its egional and county netwok of pogamme advises, Theme Goups and cosponsos, UNAIDS offes an excellent means of disseminating infomation, expeiences, best pactices and lessons leaned in social maketing. UNAIDS stimulates social maketing in the field: Myanma, the Russian Fedeation, Haiti, Cuba and Ghana Female condoms Application of social maketing to othe HIV/AIDS-elated poducts and sevices UNAIDS pomotes expanded inteest in social maketing: UNAIDS website Social maketing assessments in Bulgaia, Cuba, Guyana, Libeia, the fome Yugoslav Republic of Macedonia, and Tukey Regional Maketing Taining Exchange with pojects in Albania and Romania Foum 2000 on Social Maketing (in development) UNAIDS povides key esouces such as best pactice mateials and case studies, including: Social Maketing: An Effective Tool in the Global Response to HIV/AIDS Thee Key Lessons Leaned in Condom Social Maketing A Global Diectoy of Condom Social Maketing Pojects and Pogammes 8
Condom Social Maketing 3. Diffeent appoaches to social maketing Social maketing pogammes geneally use the existing commecial infastuctues in counties to develop and distibute specifically banded poducts such as condoms. This taditional appoach, also known as the own band model, is the most common amongst social maketing pogammes in developing counties and is closely associated with Population Sevices Intenational (PSI) and DKT Intenational, oganizations that pioneeed intenational social maketing in the 1970s and 1980s. It applies standad commecial maketing and sales techniques fo pomotion and distibution though wholesale and etail sales points to the mass maket. The social maketing oganization may eceive unbanded poducts fom intenational o national donos, o may diectly pocue quality poducts fom manufactues, and develops its own bands and packaging fo distibution. This entails the establishment of a pofessional in-county sales foce and management stuctue, fequently involving a local patne oganization. Howeve, the ability to opeate as effectively as possible in a wide vaiety of contexts is a key element in any social maketing pogamme. In most developing counties low-income populations fom the geat majoity and within it thee is a fequent need to taget specific, often difficult to access, population goups with paticula needs. In addition to woking though taditional sales netwoks involving wholesales and existing etail outlets fo consume goods, social maketing pogammes must fequently seek to develop non-taditional outlets and infomal distibution systems to meet the needs of specific goups, and even communities, within the population. The potential use of altenative distibution systems is an essential aspect of social maketing. Today, in many developing counties, socially maketed condoms ae to be found in both taditional etail outlets such as phamacies and dugstoes and non-taditional points such as bas, coffee shops, bothels, beauty palous, wokplaces, gas stations, and bus and tuck teminals. Theefoe, othe ways of social maketing of poducts have been developed and ae also common. These appoaches ae not mutually exclusive although one o moe may be applied exclusively by a pogamme o poject, o also as pats of a poject fo stengthening and impovement of an existing taditional appoach. These models, o possible appoaches to social maketing, include: Community-based systems of poduct pomotion and distibution ( communitybased distibution /CBD) whee non-pofessional sales agents ae ecuited fom among paticula goups within the geneal population. The individuals eceive basic taining in IEC and sales and ae usually ewaded financially fom small magins on thei sales. This appoach is inceasingly chosen as a means of eaching geogaphical aeas and socio-cultual goups that ae difficult to access. Many 9
UNAIDS pogammes incopoate the method to complement moe taditional, etail outlet sales; some pogammes, usually un by local NGOs, ae based entiely on the system. An innovative and pomising vaiant of the CBD appoach has ecently been developed and piloted ove two yeas in Chennai, India, by Intenational Family Health (IFH) and its local patne NGO, the Indian Institute of Community Health (IICH). In this model ( community-based social maketing /CBSM) sales agents ae ecuited fom among the geneal public as well as fom within specific goups. In addition to benefiting fom basic taining in epoductive health and fom commissions on thei sales, the agents also benefit financially fom ecuiting othes to act as educational and sales agents. CBSM is deived fom commecial netwok and multi-level maketing techniques successfully applied in developed counties, and has shown potential in apidly attaining community penetation and involvement in epoductive health issues and HIV pevention. The manufactue s model, whee suppot is povided fo the pomotion and distibution of bands developed and owned by a manufactue (foeign o local) o local manufactue s agent, fequently an impote of the poduct. The suppot usually takes the fom of gants diectly to the manufactues and/o thei distibution agents so as to educe thei commecial maketing costs and theefoe allow geate investment in key activities, such as pomotion and advetising. A etail pice significantly below the usual maket pice is the expected end esult. In contast to the taditional /own band model the manufactue s model is the least common. The appoach has been almost exclusively associated with The Futues Goup Intenational (TFGI) and its intenational, USAID-suppoted SOMARC poject. The tageted sevice delivey appoach involves planning appopiate social maketing activities, though which the poject stives to each and distibute poducts to specific taget goups, usually high-isk o othe pioity segments of the geneal public. These goups ae often inadequately seved by othe sevice delivey mechanisms, including standad social maketing activities. Thei identification usually esults fom maket segmentation studies caied out once the basic distibution stuctue to the mass maket is established, so tageted sevice delivey is often a component of pogammes mainly stuctued aound the taditional o wide commecial appoach. Howeve, many local oganizations, usually NGOs, adopt this appoach eithe fom necessity (esticted esouces) o fom paticula inteest. Thee ae many ways of applying social maketing concepts, appoaches and techniques at the national, local o community levels. Flexibility in planning and implementation ae key to successfully meeting the needs fo infomation and poducts such as condoms in the fight against the spead of HIV and AIDS. 10
Condom Social Maketing Planning and implementing social maketing pogammes is by no means esticted to lage, well-funded intenational oganizations. Local initiatives in social maketing by oganizations within the national pivate secto, including NGOs, exist in many counties. These can ange widely in size and pupose fom small, localized pojects esticted, fo instance, to taining and employing ex-commecial sex wokes in a paticula location as sales and IEC agents only fo condoms, to compehensive, full-scale epoductive health pogammes active at the national level. Of paticula inteest to local initiatives is the fact that well-managed and adequately suppoted social maketing pojects ae among the most cost-effective of health inteventions. The pojects can ecove a lage popotion of costs and evenues fom sales which can be invested in othe activities, such as capacity-building o stengthening the pogamme itself if the oganization woks exclusively in social maketing (the Social Maketing Company of Bangladesh, fo example). If the oganization has othe activities, as does PROFAMILIA in Colombia, then these evenues can also be used to subsidize these activities within a policy of coss-subsidization. The following concete examples of social maketing applied to the pevention of HIV/AIDS and STDs in diffeent counties and contexts ae offeed to illustate the vaious appoaches descibed above. The cases descibed below ae examples of the uses of these appoaches to social maketing that have been adopted in some counties by diffeent oganizations; all the cases focus on ways of condom distibution and pomotion that wee designed and implemented in esponse to diffeent situations. 11
UNAIDS 4. Case studies Community-based distibution in Haiti and Mozambique The use of individuals dawn fom the community and tained in IEC and condom pomotion and sales is key to the pefomance of the condom social maketing pogammes in seveal counties, among them Haiti and Mozambique. Howeve, the pincipal easons fo adopting this stategy, eithe on its own o complementing othe foms of condom distibution, may vay as also the foms it takes may vay. The examples of Haiti and Mozambique seve not only to illustate the potential effectiveness of CBD systems in condom social maketing, but also to demonstate diffeent easons fo the choices and diffeent ways of woking by CSM pogammes. In both counties the social maketing pogammes must deal with the difficulties involved in making condoms easily accessible to dispesed and lagely ual populations and communities. In Haiti the mountainous teain, pocketed with valleys inhabited by semi-isolated communities and seved by a pecaious tanspotation infastuctue, was a key facto in the decision to ecuit sales agents fom the communities though existing local NGOs. The agents wok to stengthen a system that includes taditional commecial distibution based on an existing commecial netwok fo othe consume goods. Significant volumes of condom sales ae achieved though the community-based distibutos (CBDs), but taditional distibution accounts fo most of the volume. On the othe hand, in Mozambique the existence of lage communities, isolated by the geogaphical teain, was much less poblematic than the fact that many yeas of civil wa had devastated the national infastuctue fo tanspotation and communications as well as the economy and an incipient commecial secto. Standad distibution of poducts was theefoe extemely difficult, even in uban aeas, and thee was no commecial distibution up-county. It was decided to focus initially on establishing a distibution system based on a netwok of locally ecuited and tained sales and motivation teams. One team was established pe povince; the ole of the motivation agent was focused on ceating demand fo condoms (paticulaly amongst high-isk goups though intepesonal communications activities), whilst the equally impotant ole of the sales agent was to meet the demand by supplying the etaile. This was necessay due to the fact that condoms in Mozambique wee still a elatively new and unknown poduct. A moe fomal, taditional means of distibution though a wholesale-etaile chain could be expected to build up ove time. In 1999, 49% of sales wee to community agents, 34% to commecial distibutos and 16% to wokplaces and NGOs. The popotion of sales to community agents in the yea 2000 is expected to be 45% and futhe eductions ae expected as the commecial secto gows. 12
Condom Social Maketing Haiti Relevant facts about Haiti Haiti has a total land aea, which is vey mountainous, of 27 600 squae kilometes, and a total estimated population of 8.1 million of whom almost 70% live in ual aeas (in contast with the aveage fo Latin Ameica and the Caibbean which is 74% uban); 55% of the population is below the age of 20. The capital, Pot-au-Pince, has an estimated population of 1.5 million. Ethnically, 95% of the population is Afo-Caibbean. Fench and Ceole ae the official languages and male/ female liteacy ates ae estimated at 48/42 %. The pincipal eligions ae Chistianity (Roman Catholic) and Vodun. Haiti is the pooest of the Latin Ameican and Caibbean counties. Its GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 250 and the vast majoity of the population live on subsistence incomes, mainly fom agicultue. Haiti anks 156 on UNDP s Human Development Index and life expectancy at bith is estimated at 54 yeas, much lowe than the egional aveage of 70 yeas. The pevalence of HIV infection amongst Haitians aged 15-49 yeas is estimated at 5.17% by the end of 1999, pehaps the highest in the egion, with an estimated 210 000 people living with HIV/AIDS and 23 000 deaths due to AIDS in 1999. Aleady by the late 1980s HIV pevalence among sex wokes tested in majo uban aeas anged fom 42% to 53%. The pevalence of STD is known to be high, and a 1992 study of male STD clinic patients found that 25 % of patients tested wee HIV-positive. Pogamme: Haiti Social Maketing fo AIDS pevention Population Sevices Intenational (PSI) has been active in social maketing fo epoductive health and eduction in high-isk sexual behaviou in Haiti since 1989, focusing its effots pincipally on poviding accessible and affodable condoms to the 13
UNAIDS low-income segments of the population fo HIV/STD pevention. By the end of 1996, two banded condoms (one male, one female) had been successfully launched on to the maket and in that yea othe contaceptive poducts (pills and injectables) wee added to the ange of poducts. Howeve, geogaphical, economic and political conditions in Haiti make it extemely difficult to implement a social maketing pogamme of egula poduct distibution though the commecial wholesale-to-etaile stuctue adopted in most counties. In Haiti the majoity of the population lives in ual aeas that ae not easily accessed due to the mountainous teain and a pecaious infastuctue of oads and tanspotation. The vast majoity of the population has little o no egula income, and, additionally, political instability and unest is a constant aspect of daily life. Thus it was decided in 1990 to implement a supplementay pogamme fo ceating a system based on the sale of poducts, mainly male condoms, togethe with elated IEC activities. This was effected though tained individuals, locally ecuited fom the communities and population goups tageted by the oveall pogamme, i.e. a system of community-based distibutos, and motivated by a easonable financial incentive usually with a commission on sales. Some othe key advantages found in Haiti by PSI of pomoting and distibuting condoms, and othe poducts, though CBDs ae: *Cedibility, as elatives, fiends and neighbous tend to be moe favouably eceived than salespeople fom outside; *Availability, as CBDs ae usually much moe easily accessed at any time of the day o night; *Pivacy and discetion, whee condoms can be obtained on a one-to-one, pesonal basis; *Effective counselling, dealing with individual needs and, especially in the case of condoms, ensuing coect and consistent use. In ode to achieve this, PSI/Haiti fomed an initial patneship with fou local NGOs, late expanding this numbe to nine with wide access to ual communities, and ceated and egisteed its own NGO, Pogamme de Santé et Infomation (PSI/Haiti). Initially, PSI tained 175 membes of the NGOs to act as wholesale distibutos selling to etail outlets and as etail sales agents to consumes. The taining sessions included such topics as STDs and HIV/AIDS pevention, social maketing goals and stategies, intepesonal communication and diect sales techniques, condom use demonstations and basic money management. Following taining, each CBD was povided with a fee stock of condoms, up to 10 etail dispenses each containing 144 condoms, in ode to begin selling and, with the esulting evenues, epuchase moe supplies afte etaining an ageed magin. PSI/Haiti in fact povided the CBDs with the means (capital) to become mico-entepeneus. Thee was an initial concen that some CBDs might pefe to sell thei condoms to highe-income goups athe than thei tageted populations and, also, that the IEC obligations of the CBD ole might be neglected in favou of sales. PSI/Haiti theefoe monitoed the activities of many CBDs and discoveed that, whilst in fact some wee selling condoms to moe affluent people, they wee not neglecting thei taget goups who epoted that condoms wee available wheneve needed. Whethe the educational obligations wee being neglected was admittedly moe difficult to evaluate, but the damatic 14
Condom Social Maketing incease in sales ecoded showed that individuals wee being convinced to puchase and use condoms, indicating that the IEC function was being caied out. The poject was vey successful. In all, moe than 3000 points of sale fo male condoms wee ceated thoughout Haiti, ensuing availability fo hundeds of thousands of customes and included, besides taditional makets and commecial sales outlets, bas, hotels and even beauty salons in both uban and emote ual aeas. Ove the fist fou yeas, monthly sales of PSI/Haiti s male condoms ( Panté ) inceased fom 3 000 to ove 400 000 pieces and continues to incease. It is estimated that at least 33% of total sales though all channels employed in Haiti wee due to CBDs, and a lage shae of egula sales outlets wee opened by these individuals. Sales gaph with total socially maketed condom sales volumes 1992-1998 millions 9 8 7 6 5 4 3 2 1 0 1.8 4.0 3.7 5.0 4.4 8.0 7.4 1992 1993 1994 1995 1996 1997 1998 1999 8.5 Futhe indicatos of success include the obsevations that, by the end of 1996, between 70 and 95% of sexually active adults, including 85% of adolescent males, 70% of adolescent females and 95% of commecial sex wokes, knew about Panté and ecognized that condoms potect against AIDS. In 1998 nealy one in five women epoted having used condoms specifically fo STD/HIV potection. At the same time, howeve, suvey esults show that both awaeness and use ae still lowe than could be expected in ual aeas and that effots must be maintained o even inceased. Accoding to epots fom PSI/Haiti, the main constaints and obstacles encounteed included: Rappot between NGOs and social maketing in pomoting HIV pevention is not automatic, and thee wee occasional conflicts between an NGO s mission and that of the poject. It was easie fo NGO salespeople to sell to moe affluent customes in the cities than to the ual outeach tagets, and to confine thei activities to selling instead 15
UNAIDS of meeting thei educational obligations. Howeve, this conflict was ecognized ealy and successfully counteed though monitoing and taining. The peiod of the poject coincided with the aftemath of the militay coup in 1991, when daily life was paticulaly difficult in Haiti. The intenational economic embago cut off impoted fuel and aw mateials, factoies and businesses closed, and hundeds of thousands of wokes wee foced into abject povety. In this uncetain envionment, highly motivated CBDs povided stability to the poject, finding ways to continue thei wok despite the poblems and danges, and continuing to open up new sales outlets and shae infomation on AIDS and its pevention. Key lessons leaned fom the expeience wee: Oveall, CBDs can make vey significant contibutions to both condom availability and accessibility, although individual pefomance can be expected to vay consideably. CBDs ae able to open new sales egions and outlets that will be egulaly seviced late by the pofessional sales foce. The diect costs to the oganization of adding CBDs to its sales foce, as opposed to pofessional salespesons, is small compaed to the benefits. Howeve, moe supevision and management time is equied, paticulaly in the fist months of opeations. Even small magins on sales can be attactive and motivating to CBDs. The pesonal income geneated by CBDs also appeas to counteact voluntee bun-out and many CBDs woked continuously fo yeas. Howeve, the income should be pesonal and not emitted to an oganization to which the CBD might belong. NGOs and community-based oganizations (CBOs) should not count on this activity as a souce of income. Nevetheless, NGOs ae much bette able to each non-taditional outlets than commecial distibutos. Condom band pomotion is most effective when accompanied not only by mass media IEC but also by intepesonal, community-based condom pomotion campaigns. To function effectively in Haiti with maximum coopeation fom govenment and intenational agencies, PSI needed to opeate though NGOs as well as though commecial distibutos. 16
Condom Social Maketing Haiti: Additional infomation Poject duation: Oiginal poject fom 1991 to 1996, but continued funding has pemitted activities though 1999. Implementing agencies: a) At the national level: Pogamme de Santé et Infomation (PSI/Haiti) managed the poject, with the diect involvement of fou national NGOs, and in patneship with the Ministy of Public Health and Population. b) At intenational level: Population Sevices Intenational (PSI) and USAID (AIDSCAP). Funding souces: USAID; additionally, the Govenment of the Nethelands, PSI Patneship Fund, Wold Bank, UNFPA, UNAIDS, the Begstom Foundation and the Summit Foundation. Poject objectives: The goal of the poject was to educe high-isk sexual behaviou and thus the tansmission of HIV/AIDS. The main objectives wee to: *Taget low income populations by making affodable condoms accessible; *Ceate consume demand based on high awaeness of coect and consistent condom use; *Reduce the incidence of othe STDs (e.g. gonohoea, syphilis, and chlamydial infection), which significantly facilitate the tansmission of HIV/AIDS. Taget aeas: The whole county, with emphasis on the ual aeas whee 70% of the population live, and whee access to condoms and othe poducts is vey limited. Moe than 3000 points of sale, ceated diectly though CBDs, and though them to non-taditional etail outlets such as night clubs, bas and beauty salons. Taget audience: Geneal and high-isk populations, especially young people (age goup 15 to 24 yeas), including female commecial sex wokes, migants and tanspot wokes. Othe CSM pojects in Haiti: None Fo additional infomation on this pogamme: PSI/Haiti Rue Theodule #1 Boudon Pot-au-Pince Haiti 17
UNAIDS Examples of condom pack and postes The PSI-banded male condom, Kapòt Panté ( Panthe ), was launched in Haiti in 1990 and is now available nationwide at a low pice of US$ 0.07 fo a packet of thee. This is an affodable pice fo a population with an estimated pe capita annual income of US$ 400 and is oughly 10 times lowe than the commecial bands. Tageted consumes wee high-isk populations, with emphasis on young people aged 15 to 24 yeas, and since 1994 on women. Intensive mass advetising depicted the Panté as denoting stength and masculinity. National media wee heavily involved in pomoting condoms fo the pevention of AIDS and in addition, education of the client was an integal pat of the wok of each CBD. The Canival peiod (Januay to Apil) is the highest isk peiod fo sexual tansmission of disease and PSI/Haiti ended the millennium with a highly visible campaign to make Canaval 2000 the safest since HIV and AIDS came to Haiti. 18
Condom Social Maketing Mozambique Relevant facts about Mozambique Mozambique has a total land aea of 801 600 squae kilometes and a total estimated population of 19.3 million of whom 66% live in ual aeas; 56% of the population is below the age of 20. The capital, Maputo, is on the coast and has an estimated population of 2.2 million. Ethnically, the population is made up of vaied goups with seveal majo languages but Potuguese is widely spoken and is the official language; male/female liteacy ates ae estimated at 58/23%. The pincipal eligions ae indigenous beliefs (60%) and Chistianity (30%). Mozambique is one of the pooest counties in the wold. Its GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 80 and the county anks 166 on UNDP s Human Development Index; half of the national income is deived fom agicultue. Life expectancy at bith is estimated at 47 yeas, below the aveage fo Afica of 51 yeas. 19
UNAIDS The pevalence of HIV infection amongst adults in Mozambique was estimated at 13.2% by the end of 1999, among the highest in Afica, with 1 200 000 people living with HIV/AIDS and 98 000 deaths due to AIDS in 1999. By 1996 HIV pevalence among antenatal women tested in diffeent locations acoss the county was found to be between 18% and 23%; in addition, the pevalence of STD is known to be high and by 1995, depending on the location, studies of male STD clinic patients found that between 23% and 40% of those tested wee HIV-positive. Pogamme: Communications and Condom Maketing fo AIDS Pevention: the pomotion of safe sex among high-isk individuals in Mozambique As a esult of the end of its civil wa in 1992, HIV tansmission ates in Mozambique ose damatically with the etun of efugees fom neighbouing counties whee HIV pevalence had been highe than in Mozambique. The govenment had a pogamme of fee distibution of condoms but this had been seveely affected by the yeas of civil wa and pospects fo impovement wee thin. In 1994 the govenment s National AIDS Contol Pogamme (NACP) invited PSI Intenational to design and implement an AIDS pevention social maketing poject to pomote safe sexual behaviou and the use of condoms as a component of the NACP s own pogamme. The oveall goal fo PSI was to impove the health of sexually active men and women and thei childen, by educing tansmission of HIV/AIDS and othe STDs. The poject that was implemented in ealy 1995 had two specific objectives: *Incease the use of condoms, paticulaly by pesons vulneable to HIV tansmission, though the intoduction, pomotion and sale of a condom specifically developed fo social maketing in Mozambique ( JeitO, the condom band name, meaning in Potuguese style o flai, which lends itself to popula slogans such as Living with Style); *Incease the demand fo condoms though the implementation of an integated behaviou change communications stategy which would pomote safe sex, especially tageting high-isk goups such as commecial sex wokes, long-distance tuck dives, STD clinic attendees, night club patons, militay and police, people with non-egula sex patnes, youth (in and out of school) and women. Having begun as a pilot poject in limited uban and peiuban aeas in fou povinces in 1995, the poject was expanded to the national level by 1996 with sales and motivation teams established in all ten povinces. Togethe with the National AIDS Contol Pogamme, fom the total of 140 disticts in Mozambique, 71 pioity disticts fo AIDS pevention wee then identified based on the following citeia: *High incidence of STDs *Common bodes with high HIV pevalence counties *High volume of tucking *High uban population density *High incidence of etuning efugees and migant laboues. 20
Condom Social Maketing The poject then ecuited and tained 65 Community Agents (CAs) fom these disticts. The CAs wee tained in intepesonal communications (fo example, each CA conducts monthly 15 small goup discussions with poject taget goups) and in sales techniques fo JeitO condoms, focusing on ensuing access to these by high-isk goups though non-taditional outlets. The CAs eceive a monthly stipend fo thei wok in communications and, additionally, a magin fom thei sales of condoms. Supevision of the CAs is povided by the PSI Povincial Sales /Motivation agent. They ae also egulaly evaluated and povided with efeshe taining when necessay. New CAs ae ecuited and tained as vacancies ae filled whilst maintaining the total of 65. The CAs have an impotant ole in the oveall poject stategy to pomote behaviou change, i.e. coect and consistent use of condoms, eduction in the numbe of sexual patnes, teatment of STDs and, paticulaly fo young people, sexual abstinence until maiage. The poject developed a famewok based on six factos deemed necessay fo behaviou change to occu: *Pesonal peception of being at isk *Education on condoms *Existence of an enabling, suppotive envionment *Ready access to condoms *Self-efficacy, o having the intent and skills to take peventive action *Appopiate condom band positioning: the JeitO band concept. In applying this famewok, the poject developed activities designed to affect each of the factos based on infomation gatheed fom the diffeent taget goups. The activities ae designed aound a mutually einfocing media mix, emphasizing intepesonal communications (dama, theate and small goup discussions) along with mass media (adio and TV spots, music videos and cassettes) and pomotional mateials. The poject has eight theate goups tained to conduct five diffeent tageted plays in evey povince of Mozambique, and on any given day it can be expected that five plays ae pefomed somewhee in the county. The esults have been impessive. To date, an estimated total of 50 000 pee education AIDS/STD sessions have been held, eaching about 1 million membes of the taget population. In addition, 150 taditional heales and some taditional bith attendants have been tained in pomoting the use of condoms with thei clients. A KAP suvey conducted in 1997 in uban and peiuban aeas evealed that 87% of espondents wee awae that condoms exist, 31% had used condoms at least once and 78% cited condoms as a means of peventing HIV infection (as compaed to 38% in a simila suvey in Malawi). Moe than 3000 condom sales outlets have been established nationwide, including non-taditional outlets fo condoms in Mozambique such as bas and clubs, kiosks and tobacconists, gas stations, maket stalls, NGOs, supemakets, steet vendos, taditional heale outlets and within wokplaces. Demand fo and sales of socially maketed condoms then ose damatically, although sales wee affected by a shotage of subsidized poduct in 1998. 21
UNAIDS Sales gaph: JeitO condoms 12 10 10.4 9.6 8 6 8.2 millions 4 2 0 2.1 4.1 1995 1996 1997 1998 1999 Accoding to epots fom PSI/Mozambique, the main constaints and obstacles encounteed included: The JeitO package of fou condoms is sold to consumes fo the equivalent of US$ 0.08 and condoms ae still dono-suppoted; in 1998 thee was a shotage of subsidized condoms due to dono shotfall. PSI in Mozambique is seen as an intenational oganization in spite of the fact that the management of the poject is 98% Mozambican and it has a close elationship with the national govenment. One solution might be to entust the capacity in social maketing to a local NGO. Key lessons leaned fom the expeience include: Govenment can be an active patne in social maketing and even include it in its own pogammes, as in this case with the NACP in Mozambique whee the condom social maketing poject is a component of the national HIV pevention stategy. The govenment ecognizes the need fo coodinating fee condom distibution though the national health system with the social maketing poject, binging condoms to the entie population egadless of the individual client s puchasing powe. This is an objective of the cuent NACP stategic plan. The pincipal facto in the success of the poject has been the emphasis given to involving the community in sales and pomotion, ight down to individual input though pee education and diect pomotion at points of sale. The success of the poject has been in lage pat due to its intensive pomotional activities not only though the media and theate pefomances, but also by the individual community-based pomotion by sales outlets, CAs, pee educatos and taditional pactitiones. 22
Condom Social Maketing Mozambique: Additional infomation Poject duation: Pilot poject in 4 povinces, 2 yeas fom 1995 to 1996. Phase I, extended to national scale, 3 yeas 1997 to 1999. Phase II, planned fo a futhe 3 yeas. Implementing agencies: a) at national level: National AIDS Contol Pogamme, Ministy of Health, PSI/Mozambique, national media. b) at intenational level: PSI/Washington, USAID. Funding souces: Fo the pilot study and Phases I and II, USAID and the Govenment of the Nethelands, with the addition of UK/DFID fom 2000. Taget aeas: Pilot poject in 4 povinces (Maputo, Sofala, Manica and Tete). Phase I, extension to national level. By Decembe 1996, the poject was opeating in all 10 povinces, and by Decembe 1998, the national stuctue was fully consolidated. Othe CSM pojects in Mozambique: None Fo additional infomation on this pogamme: PSI/Mozambique, Av. Patice Lumumba 204, C.P. 4059, Maputo, Mozambique 23
UNAIDS Community-based social maketing in India Relevant facts about India The Indian sub-continent has a total land aea of 3.3 million squae kilometes and a total estimated population of 998 million of whom 73% live in ual aeas; 49% of the population is below the age of 20. The capital, New Delhi, has an estimated population of 6 million. Ethnically, 72% of the population is Indo-Ayan, 25% is Davidian and othes account fo 3%. Thee ae moe than 14 official languages, including Hindi and English, and male/female liteacy ates ae estimated at 66/38%. The pincipal eligions ae Hindu (83%) and Islam (11%). India s GNP pe capita in 1997 was estimated by the Wold Bank to be US$ 370 and the vast majoity of the population live on subsistence incomes, mainly fom agicultue. India anks 132 on UNDP s Human Development Index and life expectancy at bith is estimated at 63 yeas, as compaed to a egional aveage of 67 yeas. 24
Condom Social Maketing The pevalence of HIV infection amongst Indians aged 15-49 yeas is estimated at 0.70% by the end of 1999, with an estimated 3 700 000 people, including childen, cuently living with HIV/AIDS. This is moe than any othe county in the wold except South Afica. India s epidemic, howeve, is divese. While some states cuently show almost no HIV infection othes have eached adult HIV pevalence ates of ove 2%. The southen state of Tamil Nadu has an estimated population of 60 million, of which some 4 million live in the capital, Chennai. The fist case of AIDS in India was epoted in Madas (now Chennai) in 1986. Local suveillance systems have shown that HIV infection has isen significantly; fo example, ates among pegnant women tipled between 1995 and 1997 to 1.25%. Bold safe-sex campaigns, including intensive condom pomotion, in Tamil Nadu have esulted in damatic inceases in condom use in isky sexual encountes. An innovative appoach to both social maketing and the CBD system has ecently been pilot-tested ove thee yeas in Chennai (Madas), India, by Intenational Family Health (IFH) and its local patne NGO, the Indian Institute of Community Health (IICH). Called Community-based social maketing (CBSM), the model is deived fom commecial netwok and multi-level maketing techniques successfully applied in developed counties in diect, peson-to-peson poduct pomotion and sales. As such, it was felt to have potential fo apidly attaining community penetation and involvement in condom pomotion and distibution and STD/HIV pevention in geneal. In the Chennai pilot test, the fist of its kind, the poducts developed and maketed in this way wee condoms and sanitay napkins. An additional attaction of the model is that CBSM offes not only an efficient means to effective pomotion of epoductive health awaeness and pactices but also the oppotunity fo significantly inceased income to many individuals and households. It would theefoe contibute diectly to impoved quality of life in the community. The CBSM expeience also illustates how some intenational donos ae willing to suppot new, even expeimental concepts and techniques in social maketing. Pogamme: axess, a community-based social maketing pilot poject Among the vaious possible ways of effecting community-based distibution of poducts, including condoms, within social maketing is that of ecuiting and taining sales agents fom among membes of the geneal public, exclusively o in addition to membes of paticula isk goups. In addition to benefiting fom commissions on thei sales of condoms, these agents would also benefit financially fom thei successful ecuitment of othes in the community to act as additional sales agents and educatos. The numbe of sales and IEC agents inceases pogessively though the establishment of sales and communications netwoks and is expected to esult in a highe demand fo infomation and poducts as the community becomes inceasingly involved. 25
UNAIDS The sales agents, o patnes, ae people fom all walks of life who coectly use quality health poducts and know why these poducts should be used. The patnes sell the poducts to othes and eceive a magin on the sales. In addition, they involve othes who will also use, sell and in thei tun involve othes. When one ecuits new patnes in this way, he/she is financially ewaded based on the volume of the poduct that was used by the people ecuited. The system diffes significantly fom standad social maketing in that healthelated infomation and poducts ae disseminated solely by individuals athe than though mass advetising and the wholesale distibution of poducts to selected commecial etailes. As infomation and poducts ae spead in this way though the community, new netwoks ae continuously ceated, esulting in inceasingly widespead and coect knowledge about family planning, the pevention of STDs and AIDS, and the use of healthpomoting poducts. In ode to test this concept fo deliveing health poducts and infomation to the less pivileged and moe vulneable segments of the population in developing counties, IFH developed the following pincipal activities: *Development of a sophisticated PC-based softwae package to egiste and tack patnes, individual sales, efeals, payments and commissions due; *Development of a family band ( axess ) fo condoms and sanitay napkins. Othe poducts such as iodized salt and soap wee late added to the poject; *Development of a taining package fo netwok maketing and health IEC; *Establishment of a specific NGO as a cente fo administation, poduct depot and taining to un the poject independently unde the band name. Othe local NGOs wee late added; *Recuitment and taining of community-based patnes in lowe-income aeas of Chennai as sales and IEC agents; *Qualitative, diagnostic eseach to monito pefomance, patne activities and identify constaints; *Fomal evaluation afte two yeas activities. The poject was designed by IFH in 1994 and 1995. Following implementation in Chennai in 1996, the CBSM activities as such began in ealy 1997 and evaluation, as planned, was conducted afte two yeas in late 1999. The pilot test was theefoe successfully completed. 26
Condom Social Maketing It is clea that basic infomation on sexual and epoductive health, including on HIV/AIDS, can be effectively disseminated though this one-to-one appoach, i.e. public health education by wod of mouth within the community. In the two yeas of implementation, 8000 patnes wee enolled and it can be assumed that each patne passed on the message about sexual and epoductive health, condoms and sanitay napkins to seveal othes, although oveall sales figues wee less than anticipated. In conducting the pilot test, the main constaints and obstacles encounteed wee: *High initial investment in time and funds in implementation, especially in infomation technology and taining in netwok sales. Nevetheless, backing fom inteested intenational donos was obtained; *Stong cultual baies inhibited ecuitment within a geneal population vey eluctant to discuss sexual mattes and sell elated poducts; *Taining the aveage peson in sales concepts and techniques poved moe difficult than expected; *Viable condom pices poved too low fo the poject to attain sustainability without heavy coss-subsidization fom othe poducts, paticulaly sanitay napkins; *Pice competition fom the commecial secto as demand fo poducts inceased with awaeness, especially fo sanitay napkins, educed the poject s expected magins on sales. The key lessons aleady leaned fom the expeience ae: *With the ight poduct mix, i.e. including condoms within a ange that includes othe less contovesial poducts, it is possible to achieve community paticipation in the pocess of public health education; *The intoduction of innovative maketing o sales pocedues and techniques, paticulaly within a sexual and epoductive health context, equies pio detailed eseach and planning in the local context; *Intensive taining and pesistent, continuous suppot to community agents can ovecome initial eluctance caused by cultual inhibitions; *Some incentive is equied by people who ae expected to eplicate thei taining ( cascade taining ); *Women ae pepaed to sell condoms as well as sanitay napkins to thei pees; *The financial incentives offeed to the community patnes must be clea, tanspaent and easily calculable fom the beginning; *To manage a social poject with a commecial bief, the non-pofit implementing agency must be pepaed to deal with the dichotomy between its social and financial objectives, and poject a clealy defined image to its paticipants and the public in geneal; *Some intenational donos who ae especially inteested in social maketing may be convinced to povide significant suppot fo pilot, expeimental activities in social maketing; *Thee is potential fo futhe development of this appoach to social maketing. 27
UNAIDS CBSM: Additional infomation Pilot test objectives: *To test whethe the pomotion, distibution and dissemination of epoductive and sexual health poducts and infomation can be effectively achieved though the application of netwok /multi-level sales and maketing techniques within a social maketing pogamme; *To test whethe CBSM tanslates in eality into an effective epoductive and sexual health stategic altenative fo low-income goups. Main focus of poject: Reduction in high-isk sexual behaviou with emphasis on HIV/STD pevention and family planning; additionally, pesonal and community income geneation. Funding souces: UK/DFID, USAID/Pofit, IFH, Packad Foundation Key collaboatos: Local manufactues of poducts (condoms and sanitay napkins), govenment at fedeal and state levels, local advetising and othe maketing sevices agencies, PSI India and YRG (Cae), a Chennai-based HIV education and cae nongovenmental oganization. Fo additional infomation on this pogamme: Intenational Family Health, Cityside House, 40 Adle Steet, London E1 1EE, United Kingdom 28
Condom Social Maketing Social maketing based on tageted sevice delivey in Cameoon Fom May 1996 to Septembe 1997, the Cameoon Social Maketing Pogamme (Pogamme de Maketing Social au Cameoun /PMSC), PSI s local affiliate, implemented a Young Adult Repoductive Health Poject in the city of Edéa. The poject integated a youth-tageted intevention within the nationwide PSI social maketing pogamme. It was designed as an opeations eseach study with the objective of assessing the effectiveness of social maketing techniques fo pomoting sexual and epoductive health among adolescents and young adults aged between 12 and 24 yeas. The Young Adult Repoductive Health Poject ( Hoizons Jeunes ) made use of a tageted sevice delivey appoach o model. In this appoach, a social maketing poject stives to each and distibute poducts to specific taget goups, o pioity segments, of the geneal public who ae often inadequately seved by othe poduct/sevice delivey mechanisms including standad social maketing activities. Tageted sevice delivey is often a stategy adopted within pogammes stuctued aound wide, commecially-based distibution. Tageting specific goups can esult fom suveys and maket segmentation studies caied out once the basic distibution stuctue to the mass maket is established and oppotunities fo impovement ae identified. 29
UNAIDS Relevant facts about Cameoon Cameoon has a total land aea, including a coastal plain and highlands, of 475 400 squae kilometes and a total estimated population of 14.7 million, of whom 55% live in ual aeas; 55% of the population is below the age of 20. The capital, Yaoundé, is in the highlands and has an estimated population of 1.1 million whilst the lage city of Douala, on the coast, has a population of 1.3 million. Ethnically, the population is made up of some 200 goups with 24 majo languages, but both English and Fench ae widely spoken and ae the official languages; male/female liteacy ates ae estimated at 75/52%. The pincipal eligions ae Chistianity (53%), indigenous beliefs (25%) and Islam (22%). Cameoon s GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 650 and the county anks 133 on UNDP s Human Development Index. Some 40% of the national income is deived fom agicultue whilst industies account fo about 22%. Life expectancy at bith is estimated at 55 yeas, slightly highe than the aveage of 51 fo Afica. The pevalence of HIV infection amongst adults in Cameoon was estimated at 7.7% by the end of 1999, with 540 000 people living with HIV/ AIDS and 340 000 deaths due to AIDS since the beginning of the epidemic. In 1993, HIV pevalence among sex wokes tested was found to be nealy 30% and, by 1996, 5% of antenatal women tested in Douala wee HIV-positive; pevalence among antenatal women tested in ual aeas in 1996 was found to be 8%. Pogamme: Hoizon Jeunes PSI s Cameoon Social Maketing Pogamme is focused on HIV/STD pevention, family planning, safe sex, impoved awaeness and peventive behaviou, and eduction in unwanted pegnancies and elated abotions (in 1996, 42% of declaed pegnancies wee teminated by abotion). Activities also include linkages with child suvival, use of mass media, pee education, and extension of the adolescent epoductive health component to othe cities in the county. PMSC s system of distibution of its poducts, including condoms, is nationwide and effected though a taditional, commecial stuctue involving wholesales, etailes and a sales foce. Its pincipal poduct is the male condom, Pudence Plus, sold in packets of fou at the low, affodable pice of US$ 0.18 pe packet (pivate condoms in the maket ae sold at between 4 and 5 times this pice). The packets have a distinctive logo of a panthe, denoting stength and masculinity, Fo the man who is sue of himself. The band mainly tagets low-income, high-isk population goups of both sexes. Pudence Plus was developed and launched in late 1989 and is sold nationwide. In 1998 sales attained 6 713 053. In 1992 a second condom was launched, Pomesse, at a highe pice (appoximately US$ 0.27 /unit) and tageting highe income goups. It theefoe sells consideably less than Pudence. To date total sales of both bands have attained almost 60 million. 30
Condom Social Maketing Socially maketed condoms in Cameoon 12 11.9 11.9 10 8 7.2 6 millions 4 2 0 3.2 1991 1994 1997 1999 Hoizons Jeunes was a key component within PMSC s social maketing stategy. Designed as an opeations eseach study, the poject s oveall objective was to assess the effectiveness of social maketing techniques fo pomoting sexual and epoductive health among young people aged 12 to 24 yeas, of both sexes, in Edéa, a coastal city of 86 000 inhabitants located about 60 kilometes fom Douala, the second lagest city in Cameoon. Changes in behaviou of young people wee compaed with those in a contol city. The concept was based on simila successful PSI pojects in Botswana and South Afica with young people. Specific objectives included: *Taget behaviou change in youth though communication and pomotion; *Effect distibution of condoms and, to a lesse extent, of Novelle oal contaceptives tageted at youth; *Detemine the effectiveness of tageted social maketing in addessing the key epoductive health poblems of young people. Duing the design phase of the poject, PMSC tained staff to incease thei undestanding of the concens of young people, and held discussions with community leades and govenment officials to ensue thei suppot fo the poject. PMSC also hied a local eseach agency to lean moe about the taget goup and help guide the poject design. 31
UNAIDS Thee main appoaches to execution wee used: *Community-based activities, with active paticipation and contibution of young people in all poject activities (e.g. development and poduction of campaign messages, adio talk-shows, bochues). *The extensive use of mass media and IEC campaigns, in suppot of the on-going pee education, with adio talk-shows and distibution of IEC mateials on epoductive health, video boadcasts, theatical sketches, and ound-table discussions, many of which tageted also paents, teaches and community leades. *PMSC developed a campaign band name, Hoizon Jeunes (Youth Hoizons) and logo to tie all poject activities and mateials togethe. Late in the poject, pee educatos developed slogans, Pensez Avant d Agi (Think Befoe Acting) and Choisissons la Vie (Let s Choose Life). The band name and slogans appeaed on pomotional mateials as well as in adio spots and pogammes. *Pee education: PMSC ecuited and tained 28 pee educatos, including 17 out-of-school youth and 11 students, in communication techniques and epoductive health topics. The pee educatos caied fanny-packs (pinted with the band name) packed with condoms to sell to youth, acted in effect as mobile sales points, and held educational sessions on weekends at popula youth hangouts in Edéa. Pee educatos also ceated and maintained Clubs Hoizon Jeunes at six junio high schools in the poject aea with club pomotional logos, T-shits and caps. Each club had about 50 membes and was led by two o thee pee educatos. Club membes oganized activities such as debates, confeences, and theate pefomances tied to epoductive health issues. The clubs geatly enhanced the poject s ability to each inschool youth. In addition, seveal Edutainment Events wee oganized in ode to make extensive use of entetainment as a way to communicate with youth, as descibed below: Duing a football match, pee educatos ode into a stadium on motocycles and used a potable micophone to give a lively AIDS-pevention pesentation and distibute bochues focused on youth; Pee educatos led a ound-table ( town meeting ) discussion among 800 community membes, including youth and thei paents; At popula video clubs, the poject showed epoductive health-elated films fo 50 CFA (appoximately US$ 0.08), much less than the pice of a movie theate ticket. Afte the films, pee educatos led a discussion and answeed questions fom viewes; The poject conducted AIDS-awaeness sessions at popula dance clubs by pepaing tapes of popula music intespesed with shot health messages. Disk jockeys in the paticipating clubs ageed to play the tapes and allowed pee educatos to conduct question-and-answe contests, giving out campaign T-shits, hats, and condoms as pizes; The poject made heavy use of the media by woking with a popula adio station, FM105, based in Douala. Two well-known DJs hosted the Hoizon Jeunes bi-weekly adio pogamme, which coveed a epoductive health topic and encouaged young people to call in with questions and comments. 32
Condom Social Maketing The esults of the poject wee evaluated by the effect on condom sales in Edéa and, in addition, by opeations eseach conducted in Edéa and a contol city. Thee was a consideable incease in the numbes of condoms sold in Edéa, and a significant impovement in undestanding by both male and female adolescents of ways of avoiding unwanted pegnancies and HIV/STD infection. Poject staff ceated new condom outlets in aeas fequented by youth and pomoted these outlets as youth-fiendly. Monthly sales at 23 sales points in Edéa ose fom about 6000 to ove 17 000 condoms between Decembe 1996 and August 1997. Thee was also significant spin-off to paents, teaches and community leades. Howeve, it was felt that the poject duation had been too shot to allow this knowledge impact to develop into common pactice. Fo this eason, PMSC is seeking funds to extend the poject, as well as to apply the successful method to othe cities in Cameoon. At the same time, howeve, some difficulties and obstacles wee epoted by PMSC, summaized as follows: *A high pecentage of young men have tied condoms but do not use them consistently. *Thee is a belief that condoms ae not necessay in tustwothy o steady elationships. *Thee is a stong stigma attached to female adolescents obtaining o caying condoms. *Diffeent motivations to condom use must be addessed: basically, young women mainly use condoms to pevent pegnancies and young men to avoid STDs. Key lessons leaned fom the poject include: Young people s exposue to poject activities was high. Afte the intevention, suveys showed that 91% of young people in Edéa had head about Hoizon Jeunes, compaed with only 5% in the contol city of Bafia. Twenty-eight pe cent of youth in Edéa wee actively involved in Hoizon Jeunes; 60% had talked to a club membe; and 47% had attended at least one club meeting. Moeove, since the local adio station had a wide each, a lage segment of the young had been exposed to the adio talk show. In a elatively shot peiod, the poject had a positive impact on seveal aeas of young people s health beliefs and behaviou. Among young women, thee was geate self-efficacy (the belief that they can take action to potect themselves) and moe contaceptive use. Fewe young women epoted having thei fist sexual expeience by age 15 and moe epoted using abstinence fo pegnancy pevention. Among men, thee was an incease in contaceptive use (methods othe than condoms) and an incease in abstinence. The poject expeience confims that involving the taget audience is one of the best ways to ensue the effectiveness of an intevention diected at young people. PMSC staff found that thei effots to involve youth in the design and implementation of the poject wee welcomed. By tapping into young people s enegy, ceativity, and desie to belong, the poject helped them find thei voices and eased thei way to becoming young adults. 33
UNAIDS Cameoon: Additional infomation Poject duation: May 1996 to Septembe 1997 Implementing agency: a) At national level: oveall poject management by PMSC. The adolescent pogamme, Hoizon Jeunes, has been integated into the nationwide social maketing pogamme; patneship with the Ministy of Public Health, the National AIDS Committee and local NGOs. b) At intenational level: PSI (Euope); limited contact with WHO and UNICEF. Funding souces: USAID fo Hoizon Jeunes ; othe donos to PMSC include Japan, Fance, GTZ and WHO. Fo additional infomation on this pogamme: PSI-PMSC, B.P. 14025, Yaoundé, Cameoun 34
Condom Social Maketing Social maketing with existing commecial bands in Kenya The Kenya Midwives poject of the Futues Goup Euope (FGE) is an example of how the pivate commecial secto can collaboate with social maketing pojects. In some cases of the manufactue s model appoach to social maketing, suppot is povided fo the pomotion and distibution of poducts developed and owned by a manufactue (foeign o local) o local manufactue s agent, fequently an impote of the poduct. The suppot can take the fom of gants diectly to the manufactues o to thei distibution agents. In othes, such as the poject descibed below, the social maketing oganization negotiates fo the pocuement of poduct and subsidizes thei distibution. In eithe event, the expected end esult is that costs and pices to the tageted population ae significantly below the usual maket pice. Relevant facts about Kenya Kenya has a total land aea, including a coastal plain and highlands, of 580 400 squae kilometes and a total estimated population of 29.5 million of whom 72% live in ual aeas; 62% of the population is below the age of 20. The capital, Naiobi, is in the highlands and has an estimated population of 2.1 million whilst the next lagest city, Mombasa, on the coast, has a population of almost 500 thousand. Ethnically, the population is made up of vaied goups with seveal majo languages, but both English and Swahili ae widely spoken and ae the official languages; male/female liteacy ates ae estimated at 86/70%. The pincipal eligions ae Chistianity (70%) and indigenous beliefs (10%). Kenya s GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 280 and the county anks 134 on UNDP s Human Development 35
UNAIDS Index. Half of the national income is deived fom agicultue whilst industies and constuction account fo about 41%. Life expectancy at bith is estimated at 54 yeas, slightly highe than the aveage of 51 yeas fo Afica. The pevalence of HIV infection amongst adults in Kenya was estimated at 13.95% by the end of 1999, with 210 000 people living with HIV/ AIDS and 660 000 cases of AIDS having occued since the beginning of the epidemic. By 1995, HIV pevalence among antenatal women tested in Naiobi was found to be 25%, and 55% of sex wokes tested in Mombasa wee HIV-positive. The pevalence of STD is known to be high, and a 1996 study of male STD clinic patients in Naiobi found that 14% of those tested wee HIV-positive. Pogamme: Expanding Family Planning Sevice Delivey though Maket Day Midwives in Kenya Kenya is a county in which social maketing, including that of condoms, has been extensively employed in the social and health sectos. In addition to the Futues Goup Euope poject unde consideation, at least two othe social maketing pojects ae aleady well established: PSI/Kenya and the FGE/Kenya HIV/AIDS Pevention and Cae Poject. Thee was thus aleady consideable national expeience in social maketing when the Maket Day Midwives poject began in 1996. The main issue addessed by the poject was the impovement of access to affodable epoductive health poducts and sevices by population segments that wee vey difficult to each by taditional means in this case people in emote ual aeas. The stategy chosen was to be pesent at locations moe easily accessed by the pogamme but egulaly fequented by these people. Thus it was decided to establish epoductive health kiosks in makets in 12 disticts in Nyanza Povince and the Geate Naiobi Aea, each staffed by a specially tained midwife. The taget audience was middle and low-income visitos to makets coming fom emote and inaccessible aeas. Initial emphasis was placed on eaching women but, in esponse to the inteest and demand that esulted, this was gadually expanded to include childen, adolescents of both sexes and adult men. A total of 38 nuse/midwives wee selected, tained and set up to opeate in specially built wooden kiosks in the diffeent makets, extending sevices and poducts to these peviously uneached populations. The initial emphasis was on family planning and mothe and child health, but this was expanded to include peinatal cae and pevention of STD/HIV/AIDS. All the kiosks wee supplied with contaceptives and male condoms, medical supplies and vaccines, family planning pomotion kits and STD Syndomic Management kits. The commodities wee pocued at negotiated pices fom phamaceutical and condom manufactues. Thus, the midwife kiosks pogessively became infomal mini-clinics, cateing fo the epoductive and sexual health needs of this had-to-each population. 36
Condom Social Maketing Success was admittedly difficult to measue. A main achievement was the widespead acceptance of the kiosks by the population and the local authoities. The numbe of clients at the 38 kiosks inceased by 600% afte 2 yeas of opeation, fom 164 600 to 989 000 pe annum. Accoding to FGE/Kenya, the main constaints encounteed involved eligious (Chistian) esistance to what was oiginally advetised as a family planning poject. Thee was also esistance by the local authoities to the new idea of health cae by midwifemanned maket kiosks. Both issues wee ovecome and the poject was accepted because of the enomous divesity of sevices offeed, of which family planning was only a pat. The local authoities wee involved in the publicity dives, though billboads, puppetees, the media, and the paticipation of leading secula and eligious pesonalities. This, combined with the enthusiastic esponse of the population in these emote aeas, finally pesuaded the distict authoities to give thei full coopeation. The willing paticipation of the Distict Health Management Teams (DHMTs) has also been an impotant facto. The pincipal lesson leaned fom the poject is that offeing low-cost, high-quality health cae access, including epoductive health, HIV/STD, MCH and pimay cae, on maket days in emote, unde-seved aeas, though the mechanism used (kiosks, intensive pomotion, client assessment, efficient supply system, social mobilization), meets with enthusiastic public suppot. A stong motivational element is that midwives ae vey pooly paid in Kenya. This poject povides them with salay supplements, which povide a eal incentive fo thei active paticipation and suppot. Possible initial objections by local and eligious authoities can be ovecome once the usefulness of the poject to the public is clealy visible. The method lends itself to extension within Kenya and to othe counties. UK/ DFID has used the poject as an example of an effective gass-oots pogamme with high each at a low cost. Kenyan Condom Pomotion postes 37
UNAIDS Kenya: Additional infomation Poject duation: 3 yeas, 1996-1999 Implementing agency: The Futues Goup Euope (Kenya), which acts as poject manage and evaluato. Othe involved paties include: a) At national level: Pivate Midwives Pactitiones (PMP) Society, Ministy of Health and local govenment, ACOBOS, FPAK, distict authoities b) At intenational level: The Futues Goup Euope Funding souce: UK/DFID Taget audience: Middle and low-income visitos to makets in 12 disticts in Nyanza povince and the Geate Naiobi Aea; a total of 38 makets Specific poject objectives: *Impove and expand the accessibility of quality FP methods and sevices; *Stengthen and impove the quality and ange of sevices offeed by midwives at kiosks in the makets; *Establish safe sexual behavious among had-to-each populations; *Incease income flows fo the midwives and the PMP Society; *Expand maket base of contaceptive poducts and FP sevices. *Incease the numbes of beneficiaies of the poject, especially women of childbeaing age, adolescents, and those at paticula isk of HIV/ AIDS. Fo additional infomation on this pogamme: Futues Goup Euope (Kenya), PO Box 75367, Naiobi, Kenya 38
Condom Social Maketing A local pivate secto initiative in social maketing in Colombia Planning and implementing social maketing pogammes, fom small-scale pojects tageted at specific goups to lage and compehensive nationwide pogammes, is possible fo local oganizations in developing counties. Many such pojects exist aound the wold. The successful example of the Asociación Colombiana Po-bienesta de la Familia (PROFAMILIA) in Colombia substantiates this possibility. It also illustates how social maketing can significantly contibute towads the ecovey of unning costs in middleincome counties, o even the attainment of financial self-sufficiency, by a national, independent NGO woking in epoductive health though a stategy of coss-subsidization. Relevant facts about Colombia Colombia has a total land aea, including a coastal plain, high Andean mountains and valleys, of 1 139 000 squae kilometes and a total estimated population of 41.6 million of whom 73% live in uban aeas; 48% of the population is below the age of 20. The capital, Santafé de Bogotá, is in the cental highlands and has an estimated population of 5.6 million. Ethnically, the population is mainly of acially mixed descent but includes whites, Afo-Ameicans and native Ameicans. Spanish is spoken thoughout the county; male/female liteacy ates ae both estimated at 91%. The pincipal eligion is Chistian (Roman Catholic). 39
UNAIDS Colombia s GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 1910 and the county anks 51 on UNDP s Human Development Index. Half of the national income is deived fom agicultue whilst industies account fo about 31%. Life expectancy at bith is estimated at 71 yeas, typical fo South Ameica. The pevalence of HIV infection amongst adults in Colombia was 0.31% by the end of 1999, close to that of othe South Ameican counties, with an estimated 71 000 people living with HIV/AIDS and 1 700 deaths due to AIDS in 1999. In 1994, HIV pevalence among antenatal women tested was found to be 0.5%. Pogamme: Condoms, Towads a Definitive Segmentation of the Maket PROFAMILIA is a pivate, independent and non-pofit oganization that has povided education and compehensive public sevices in family planning and epoductive health in Colombia since 1965, and has been affiliated with the IPPF since 1967. HIV/ AIDS pevention was included in its activities as of 1987. PROFAMILIA s mission is to seve the needs of Colombia s lowe-income goups, which account fo almost 80% of the population. The oganization has gown steadily ove the yeas since its founding to the point whee it now accounts fo ove 50% of family planning and epoductive health sevices in the county. It is cuently the lagest national, pivate oganization of its kind in the wold Although initially heavily dependent on foeign donos fo funding its activities, PROFAMILIA soon adopted a successful stategy of divesification of its sevices with the goal of eventually achieving sustainability and financial self-sufficiency. The social maketing of contaceptive poducts, including condoms, was a key element of that stategy and this activity was begun in the ealy1970s. By commecially distibuting quality assued-condoms and othe elevant poducts at costs affodable to lowe-income goups, and at the same time poviding compehensive clinical sevices elated to epoductive health, PROFAMILIA has been able both to subsidize its coe family planning activities fom the modest pofits that esulted fom divesification, and at the same time come close to vitual financial self-sufficiency. 40
Condom Social Maketing The effects of this stategy may be seen in the following chat: PROFAMILIA Souces of income (US $s) 25 000 20 000 15 000 10 000 5 000 0 Local income Intenational income Total income 1987 1995 1997 Today PROFAMILIA is 90% self-sufficient, with some 65% of its income deived fom its divesified sevices and 18% fom its social maketing (SM) activities. Key easons fo PROFAMILIA s success with SM: *Top management commitment to adopting and investing in commecial maketing and sales techniques, staffing and motivational taining of field and clinic staff in the concepts and aims of social maketing; *Management emphasis on ceativity and willingness to ty new ideas; *Addition of clinics and community-based health wokes in the sales stuctue; *Regula stategic planning and eviews including cost-benefit analyses of altenatives and options, fequent consume and opeations eseach 41
UNAIDS studies on effectiveness, satisfaction, tends, needs, maket segmentation, and poduct development, paticulaly fo pack designs, picing and communications; *Initial, stat-up suppot fom intenational donos, paticulaly with subsidized, quality-assued poducts; *Cultivation of national and local govenment suppot, especially amongst policy-makes and paticulaly egading impot duties, picing and distibution pemits. PROFAMILIA s social maketing pogamme distibutes a ange of contaceptive poducts, including condoms, though a national netwok of almost 4 000 etailes and 140 wholesales. The county is divided into fou egions, each with a sales team and each membe of which has a sales distict o, in some cases, a specific population goup to seve. Each team is attached to one of PROFAMILIA s 35 clinics aound Colombia and in addition all the clinics have depots and sales countes fo individual clients, geneal consumes and wholesales. Lage volumes fo some wholesales ae dispatched fom a cental waehouse in the capital city, Bogotá, which also distibutes to PROFAMILIA s egional depots. In ual and maginal uban aeas, community-based health wokes complement the sales netwok as distibutos. All staff and voluntees involved in distibution and sales ae tained in AIDS and STD pevention as well as family planning, and povided with specific IEC mateials fo thei clients; communications mateials fo condoms focus on double potection. Condoms wee fist intoduced into Colombia by PROFAMILIA with the development and distibution of its social maketing band Tahiti in 1976. Two additional bands have since been intoduced by PROFAMILIA, Confiamo in 1993 and Piel in late 1999. The acceptance of condoms by Colombians has esulted in the appeaance ove the yeas of a numbe of competitive oganizations and bands seeking to follow the tail blazed by PROFAMILIA. Competition inceases yealy. If in 1997 PROFAMILIA still led the maket in total sales, today it anks fouth, although Tahiti emains the most popula band. Consideably moe significant than PROFAMILIA s pefomance and maket position in commecial tems is the fact that due to this oganization s effots the availability and accessibility in Colombia of quality-assued, affodable potection fom both unwanted pegnancies and infection by STDs and HIV has been enomously inceased. Fom vitually nothing in the ealy 1970s, when PROFAMILIA intoduced the fist band, total condom sales today in Colombia aveage an estimated 40 million units a yea. By the end of 1998, PROFAMILIA alone had sold 133.5 million condoms since the launch of Tahiti in 1976. It is woth noting that of these 133.5 million, 45 million wee donated by intenational development agencies, mainly USAID, so that affodable pices to lowe-income goups could be assued. Howeve, these donations pogessively declined in time, and PROFAMILIA has inceasingly pocued its condoms on the intenational maket (thee ae no manufactues of latex condoms in Colombia), mainly fom the United States, Gemany and, moe ecently, China and Thailand. 42
Condom Social Maketing Sales gaph: ba chat, PROFAMILIA total condom sales 8 7 6 5 4 3 2 millions 1 0 1977 1987 1997 1998 1999 By 1995, and within an oveall contaceptive pevalence ate of 72%, condoms wee the fouth pefeed method egulaly used among maied women of epoductive age in geneal (4%) and had been tied by 20%. Howeve, they wee also the second method most used amongst unmaied but sexually active women (38%). In addition, tial and use is known to have inceased significantly as awaeness about AIDS inceases, paticulaly among young men. Condom awaeness amongst youth is high: by 1994, 76% of young people knew of condoms and 72% knew whee to obtain them. Although the taget consumes o clients of PROFAMILIA s condom social maketing activities ae pimaily sexually active adult males, the inceasing impotance and paticipation of women in condom usage and puchase is ecognized and taken into account. The success of condom social maketing pogammes should be evaluated not only in tems of sales and distibution figues but also though thei impact within the wide social and epoductive health context. PROFAMILIA invests heavily in maket, consume, and demogaphic health suveys in ode to monito and evaluate its pefomance, identify tends and oppotunities, and plan effectively. The individual condom bands wee developed entiely within PROFAMILIA. Outside supplies fo packaging designs and communications wee contacted as needed, 43
UNAIDS such as advetising agencies, pintes, and a cental media agency. With key decisions based on eseach, the bands, although geneally aiming at adult males, ae positioned in the maket fo specific taget goups within the population that include women and sexually active young people. Cuently, thee ae no othe condom social maketing pojects in Colombia. Condom bands socially maketed by PROFAMILIA ae: TAHITI: With a ecommended etail pice equivalent to US$ 0.16 pe condom, the band is positioned in the lowest pice segment and theefoe tageted at the highest numbe of people. It is the lowest pice within PROFAMILIA s line of condoms and one of the lowest in the maket. Its pimay taget goup is made up of young adults and adults aged 25 to 46 within low to middle-income goups. CONFIAMOR: Positioned in the mid-pice segments, at US$ 0.25/unit, fo young adults and adults aged 25 to 45 within middle to high-income goups. PIEL: At the equivalent of US$ 0.35/condom, it is positioned as a pemium-piced band pimaily fo sexually active young people and adults within middle to highest-income goups. The band was launched in late 1999 in esponse to a need fo a band at this high-income level but also with the aim of inceasing PROFAMILIA s financial etuns fo its coss-subsidization plans fo 2000 onwads. 44
Condom Social Maketing The main constaints and obstacles encounteed by PROFAMILIA in its social maketing of condoms wee epoted as follows: Constaints Restictions exist on the times that condom infomation is allowed in electonic media, especially TV Smuggled /black maket cheap condoms in the maket Making sue pack designs do not get out of date and ae always attactive and appealing Maintaining maket shae is demanding of esouces Limited esouces fo use of electonic media in pomotion Action taken Respecting the allowed times PROFAMILIA sales staff emphasize the need fo buyes to demand quality; Quality awaeness campaigns which explain about expiy dates, seals of appoval etc.; Sales pomotions: adding exta condoms to the pack but maintaining the oiginal pice; Use of the PROFAMILIA name as a value-added featue on the packaging Update, even edesign packs, based on infomation and feedback fom the sales foce and consumes Develop specific bands, incease the line of bands tageted at specific maket and consume segments Consume eseach, including maket segmentation and consume behaviou studies; Media planning to identify the most appopiate media channels fo diffeent maket segments The key lessons leaned by PROFAMILIA fom its social maketing pogamme ae: If coss-subsidization is adopted within an oganization in ode to fund othe activities, the planning should conside maximizing magins on sales, i.e. condom social maketing is not an end in itself but a means to aid in achieving the oganization s wide objectives. In a situation whee funds and esouces ae always limited thee is a pemium on ceativity and initiative, paticulaly fo pomotional and communication activities. Building team spiit is key, motivated by the wide social objectives of the oganization. 45
UNAIDS Fo additional infomation on this pogamme: PROFAMILIA, Depto. de Mecadeo Social, Calle 34 No. 14-52, Santafé de Bogotá DC, Colombia 46
Condom Social Maketing 5. Key Lessons This booklet is offeed as a key mateial within the UNAIDS Best Pactice Collection which seeks to disseminate, as widely as possible, woking pactices aound the wold that have been tied o adopted in esponse to the spead of HIV/AIDS and STDs. The aim of the Collection is not necessaily to pomote the activities o pactices pe se as best solutions to the poblems fo which they wee oiginally adopted, but, moe impotantly, to povide a souce of lessons leaned that may save othes in the field consideable effot, esouces and time. Each of the social maketing county pogammes descibed povides valuable lessons that may be applied in othe counties and cicumstances, whethe in planning new pojects o in woking towads expanding o impoving existing pogammes. These lessons ae included in the sections on each poject. Howeve, some geneal issues ae elevant as key points to be consideed. 1. Social maketing fo HIV/AIDS and STDs is at pesent lagely focused on condoms. This will not always be so. UNAIDS advocates social maketing, and paticulaly the social maketing of condoms, as a key stategy in the fight against the global HIV/AIDS pandemic. The case studies descibed hee have much to offe both new and othe on-going condom pomotion pojects. Howeve, although male and female condoms ae cuently the only manufactued poducts that povide potection against infection fom HIV and many STDs, othe poducts, such as micobicides and vaccines, ae in development and will one day become available. They will be moe quickly and easily accessed by those who can affod thei commecial pice. Howeve, in developing counties, the vast majoity of the population will find it difficult, fequently impossible, to avail themselves of the new poducts and inceased potection. The lessons to be leaned fom the past expeience and expeiments in condom social maketing can help significantly in making new poducts and sevices moe widely available and accessible as quickly as possible. 2. Maketing, and consequently social maketing, is a vey flexible and adaptable technique. The concepts and pinciples of maketing can be applied to almost any poducts and sevices and on vitually any scale, whethe fo commecial o social ends. No is thee a single model of maketing that is necessaily any bette than any othe; the pactical application of the technique s guiding pinciples may take many foms, depending on cicumstances and aims. The few examples of applied social maketing descibed in this booklet illustate the ange and flexibility of the discipline, and how it may be adapted to deal with widely diffeing situations, constaints and oppotunities. Social maketing pojects and pogammes can be lage and nationwide o, as appopiate, small and tageted at specific locations o goups within the population. A pogamme may stand alone o be a component of a lage, moe compehensive poject; similaly, a social maketing pogamme may contain within itself diffeent tactics and stategic appoaches, such as when taditional poduct distibution though commecial wholesales to shops is complemented with community-based distibution to individuals. No, as has been seen, does a social maketing pogamme necessaily equie the exclusive use of expeienced maketing pofessionals. People dawn fom the geneal public o fom specific, tageted goups can be effectively involved in a poject s design and implementation. 47
UNAIDS 3. Reseach is fundamental to effective social maketing and achieving behaviou change. In designing and implementing a social maketing poject, detailed knowledge of the taget goup s situation and context is essential: assessing the availability of and degees of accessibility to needed poducts and sevices, and discoveing the goup s values, attitudes, habits, needs and wants in elation to the poject s goals, ae necessay fo the identification of oppotunities and means fo action. In othe wods, the planning pocess and subsequent eviews, as well as the monitoing and evaluation of pefomance and pogess following implementation, must be guided by elevant, eliable, upto-date infomation and data. Social maketing theefoe equies compehensive maket and consume eseach, and seveal of the cases descibed above have illustated its impotance. The depth and scale of the eseach conducted will of couse depend on the amount and quality of available esouces, but even whee esouces ae limited, whethe fo lack of funds o technical know-how o both, it is possible to collect and analyse eliable infomation. Whee technical esouces fo eseach ae limited, obtaining and acting upon knowledge about tageted goups is often made easie, o even fully achieved, though the patneships that ae inceasingly being foged between social maketing pojects and local, often community-based, oganizations. Many of these joint pojects ae set up in ode to impove the each of social maketing to specific goups o population segments but individuals can be tained also in collecting infomation fom thei pees, though individual inteviews and focus goup discussions, as well as in sales and distibution. 4. The measue of success of a social maketing pogamme is much moe than the volume of poduct sales achieved. The success of social maketing should be evaluated not only in tems of sales and distibution figues but also though thei impact within the wide social and epoductive health context. Techniques and indicatos that can document the impact of pogammes above and beyond sales figues exist, such as measues of awaeness, ecognition and acceptance of isk, behaviou and social change, and pogamme each, and othes ae being developed. 5. Thee is a need fo inceased and expanded implementation of social maketing in the fight against HIV and STDs. Social maketing has been applied towads the impovement of sexual and epoductive health since the 1970s. Its contibutions in this field have been significant, especially in expanding access to epoductive health sevices and poducts in developing counties. Within the aea of HIV/AIDS and STDs, the social maketing of male and female condoms to low-income and high-isk goups is becoming inceasingly widespead and has esulted in many counties in geatly impoved access to condoms. Fo example, in 1991 social maketing pogammes opeated in 37 developing counties and sold about 575 million condoms; by the end of 1999, pogammes existed in almost 60 developing counties and sold ove 900 million male and female condoms. Nevetheless, thee is still oom fo expansion and futhe gowth. Many moe counties can adopt social maketing as a key stategy within thei HIV and STD pevention pogammes and many of those with existing pogammes would benefit fom assessing thei needs fo impovement. It is hoped that the expeiences and lessons leaned fom the pogammes descibed hee may contibute to this. 48
Condom Social Maketing 6. Selected Bibliogaphy (pincipal souces) UNFPA. The New Geneations: The State of the Wold Population, 1998. UNFPA. Six Billion - A Time fo Choices: The State of the Wold Population, 1999. UNAIDS. Social Maketing: An Effective Tool in the Global Response to HIV/AIDS, UNAIDS Best Pactice Collection, 1998. UNAIDS and PSI. Social Maketing: Expanding Access to Essential Poducts and Sevices, 1999. UNAIDS. Global Diectoy of Condom Social Maketing Pojects and Pogammes (daft), 1999. Johns Hopkins School of Public Health. Closing the Condom Gap, Population Repots, Vol. 27, No. 1, Apil 1999. Cente fo Communication Pogams, Johns Hopkins Univesity. Condoms CD-ROM, 1999. UNAIDS WHO. AIDS epidemic update: Decembe 1999. PSI. The Ceative Edge: Social Maketing fo AIDS Pevention, 1998. Population Sevices Intenational (PSI). Futues Goup Euope, Intenational Family Health (IFH), Asociación Colombiana Po-bienesta de la Familia (PROFAMILA). Intenal epots on pogamme activities. UNAIDS WHO. County Epidemiological Fact Sheets on HIV/AIDS and Sexually Tansmitted Diseases, UNAIDS website, July Novembe 1999. 49
The Joint United Nations Pogamme on HIV/AIDS (UNAIDS) is the leading advocate fo global action on HIV/AIDS. It bings togethe seven UN agencies in a common effot to fight the epidemic: the United Nations Childen s Fund (UNICEF), the United Nations Development Pogamme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Intenational Dug Contol Pogamme (UNDCP), the United Nations Educational, Scientific and Cultual Oganization (UNESCO), the Wold Health Oganization (WHO) and the Wold Bank. UNAIDS both mobilizes the esponses to the epidemic of its seven cosponsoing oganizations and supplements these effots with special initiatives. Its pupose is to lead and assist an expansion of the intenational esponse to HIV on all fonts: medical, public health, social, economic, cultual, political and human ights. UNAIDS woks with a boad ange of patnes govenmental and NGO, business, scientific and lay to shae knowledge, skills and best pactice acoss boundaies. Poduced with envionment-fiendly mateials
Joint United Nations Pogamme on HIV/AIDS UNICEF UNDP UNFPA UNDCP UNESCO WHO WORLD BANK Joint United Nations Pogamme on HIV/AIDS (UNAIDS) UNAIDS - 20 avenue Appia - 1211 Geneva 27 - Switzeland Telephone: (+41 22) 791 46 51 - Fax: (+41 22) 791 41 87 E-mail: unaids@unaids.og - Intenet: http://www.unaids.og $10.00